Californians Are Voting On Another Dialysis Ballot Measure. What To Know About Prop. 23.

California voters are again being asked to weigh in on regulations for dialysis companies and the clinics they operate.

November's Proposition 23 would create new rules for these clinics, which provide blood replacement therapy for people whose kidneys are not functioning properly. Clinics would need to have a physician onsite during all dialysis treatments, report infection data to state and federal governments, get state approval to reduce services or close clinics and treat all patients equally regardless of how they pay for care. 

The measure is supported by a major labor union called the Service Employees International Union-United Healthcare Workers West. They’re arguing that dialysis clinics are unsafe for patients due to a lack of staffing and accountability.

Opponents say any changes to clinic requirements should be made through industry regulations or legislation, and that voters shouldn’t be placed in the middle of a financial battle between labor unions and the dialysis industry.

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In 2018, Californians voted against Proposition 8, which would have capped dialysis profits. Opponents of the measure, including dialysis companies DaVita and Fresenius Medical Care, spent more than $100 million fighting the initiative. 

So far, the two companies have raised more than $85 million to fight Proposition 23.

Under federal rules, a doctor who refers a patient for dialysis must visit the patient during dialysis treatment at the clinic at least once per month. Clinics must employ a physician to serve as medical director, though current regulations don’t specify how often that person needs to be on site.

The current rules also require clinics to report some dialysis-related infection information to the U.S. Centers for Disease Control and Prevention. 

“This industry is highly regulated as it is,” said Dr. John Mouratoff, a nephrologist with Sutter Health who opposes the measure.

He said while it could make sense to improve staffing ratios in dialysis clinics, having a physician onsite for every treatment will just cost the operators money without a major benefit to the patient.

“That’s going to, unfortunately, lead to many, many units closing down, lack of access to care, and increased costs for all consumers in California because this will lead to hospitalizations,” Mouratoff said. 

The measure could have a disproportionate effect on rural clinics, and operators will likely have a hard time finding physicians to meet the new requirements.

The nonpartisan Legislative Analyst’s Office wrote in a report that the onsite doctor requirement would increase clinic operations costs “by several hundred thousand dollars annually on average,” but wouldn’t lead to major closures.

The report authors said the most likely scenario is that clinic operators would negotiate with some payers to receive higher payment rates to make up for the costs imposed by the measure, or continue to operate with reduced income.

Steve Trossman, a spokesperson with the labor group funding the ballot measure, says dialysis companies have huge stores of profits and should be able to make these changes easily without risking financial peril.

“We believe these are common-sense changes,” he said. “We believe they can easily accomplish this and still make a really healthy profit.”

But many opponents say the measure is just a union attack on dialysis companies that isn’t about patients at all.

“That they are at the center of a battle over financial spoils for the second time in as many years is an unfortunate comment on the nation’s health care system as well as the state’s initiative process,” wrote the San Francisco Chronicle editorial board in a statement of opposition. “Vote no in the hope of discouraging any further reliance on this tactic."

About 80,000 Californians receive dialysis from about 600 licensed clinics.